Cognitive training for substance use disorders: Neuroscientific mechanisms

Neurocognitive and clinical profile of male patients with substance use disorder in early remission phase with and without comorbid depression

Substance Use Disorder (SUD) represents one of the most frequent conditions worldwide which commonly coexists with major depressive disorder (MDD). This comorbidity (SUD + MDD) is one of the most prevalent with patients showing certain social and clinical characteristics that could lead to a worsening of their cognitive performance. However, despite these particularities, only a few studies have addressed the possible differences in cognitive performance between patients with SUD + MDD compared with those with SUD-only patients. Therefore, the aim of this study is to examine the clinical and cognitive profile of patients with SUD + MDD vs. SUD-only who are in early remission phase. For this purpose, 271 male patients underwent a clinical and neuropsychological assessment (SUD + MDD group: N = 101; SUD-only group: N = 170). Results indicated that SUD + MDD patients showed worse cognitive performance than SUD in visuospatial reasoning, verbal memory and learning, recognition, and processing speed even after a 3-month period of abstinence. Furthermore, these patients exhibited more self-reported prefrontal symptoms, as well as worse social and clinical conditions. This study indicates that the neurocognitive and clinical profile of patients with SUD + MDD could represent a risk since their characteristics have been associated with poorer recovery and prognosis. Our results could be helpful in clinical practice highlighting the need for cognitive remediation strategies in these populations, providing information that would allow the implementation of more appropriate treatments and preventive strategies.

Human laboratory models of reward in substance use disorder

Human laboratory models in substance use disorder provide a key intermediary step between highly controlled and mechanistically informative non-human preclinical methods and clinical trials conducted in human populations. Much like preclinical models, the variety of human laboratory methods provide insights into specific features of substance use disorder rather than modelling the diverse causes and consequences simultaneously in a single model. This narrative review provides a discussion of popular models of reward used in human laboratory research on substance use disorder with a focus on the specific contributions that each model has towards informing clinical outcomes (forward translation) and analogs within preclinical models (backward translation). Four core areas of human laboratory research are discussed: drug self-administration, subjective effects, behavioral economics, and cognitive and executive function. Discussion of common measures and models used, the features of substance use disorder that these methods are purported to evaluate, unique issues for measure validity and application, and translational links to preclinical models and special considerations for studies wishing to evaluate homology across species is provided.

Tackling addictive behaviors through memory suppression: A scoping review and perspective

Forgetting is often viewed as a human frailty. However, over the years, it has been considered an adaptive process that allows people to avoid retrieval of undesirable memories, preventing them from suffering and discomfort. Evidence shows that the ability to suppress memories is affected by several psychopathological conditions characterized by persistent unwanted thoughts, including anxiety and posttraumatic stress disorders. Nevertheless, memory suppression (MS) mechanisms in addiction-a clinical condition characterized by recurrent drug-related thoughts that contribute to repeated drug use-have received little attention so far. Addiction theories reveal that drugs change behavior by working on memory systems, particularly on declarative memory, which is related to the retrieval and encoding of drug-related memories. In this review, the main behavioral and neurofunctional findings concerning the Think/No-Think task-an adaptation of the classical Go/No-Go tasks typically used to evaluate the suppression of motor response-are presented. We then show how the memory system can be involved in the craving or anticipation/preoccupation stage of the addiction cycle. Subsequently, the study of MS in the context of addictive behaviors is highlighted as a promising approach for gaining knowledge about the mechanisms contributing to the continuation of addiction. Finally, we discuss how interventions aiming to strengthen this ability could impact the anticipation/preoccupation stage by (i) reducing the accessibility of drug-related memories, (ii) decreasing craving and attention toward drug-related stimuli, and (iii) improving overall inhibition abilities. In conclusion, this review aims to illustrate how the study of MS may be a valuable approach to enhance our understanding of substance use disorders by unveiling the underlying cognitive and neural mechanisms involved, which could have important implications for addiction treatment.

Cognitive Alterations Associated with Remission and Alcohol Dependence Severity in Ethnically Diverse Patients of Siberia

Background

Impaired cognition in individuals with alcohol dependence may be associated with increased relapse risk. It has been recorded in more than half of patients during six months after treatment. In certain ethnic groups, for example, Tuvinians, the indigenous people of Siberia, relapses occur in extremely short periods of one to three months after treatment. An approach currently used to alcohol dependence treatment may be less effective for these patients.

Objective

The study aimed to investigate cognitive sequelae in indigenous Tuvinian patients with alcohol dependence.

Methods

The sample included 166 patients, 74 of indigenous ethnicity (Tuvinians) and 92 non-indigenous white patients. Data on inhibitory control, cognitive flexibility, attention, and working memory were collected from all the patients and processed using cluster analysis. The clustering data were then complemented by indicators of disorder dynamics, impulsivity, and emotion regulation.

Results

The clustering procedure revealed groups with severe cognitive sequelae. More than four-fold attention decrease was found in 43.5% of non-indigenous patients, and more impaired cognitive flexibility was revealed among 60.8% of indigenous patients. Groups with severe cognitive sequelae had higher impulsivity, maladaptive emotion regulation, more hospitalizations, faster disease progression, and shorter remissions. The latter was significantly reduced to 90 days on average in the severe group of indigenous patients versus 135 days of remission in the non-indigenous severe group.

Conclusion

Results obtained may advance tailored intervention in alcohol-dependent patients of the indigenous Tuvinian ethnicity. While little is still known about the alcohol dependence course and consequences in the indigenous Tuvinians of Siberia, this study contributes to the global mental health data on alcohol abuse and dependence in indigenous communities.

Working memory performance predicts, but does not reduce, cocaine- and cannabinoid-seeking in adult male rats

Background

Cognitive deficits reflecting impaired executive function are commonly associated with psychiatric disorders, including substance use. Cognitive training is proposed to improve treatment outcomes for these disorders by promoting neuroplasticity within the prefrontal cortex, enhancing executive control, and mitigating cognitive decline due to drug use. Additionally, brain derived neurotrophic factor (BDNF) can facilitate plasticity in the prefrontal cortex and reduce drug-seeking behaviors. We investigated whether working memory training could elevate BDNF levels in the prefrontal cortex and if this training would predict or protect against cocaine or cannabinoid seeking.

Methods

Adult male rats were trained to perform a 'simple' or 'complex' version of a delayed- match-to-sample working memory task. Rats then self-administered cocaine or the synthetic cannabinoid WIN55,212-2 and were tested for cued drug-seeking during abstinence. Tissue from the prefrontal cortex and dorsal hippocampus was analyzed for BDNF protein expression.

Results

Training on the working memory task enhanced endogenous BDNF protein levels in the prelimbic prefrontal cortex but not the dorsal hippocampus. Working memory training did not impact self-administration of either drug but predicted the extent of WIN self-administration and cocaine seeking during abstinence.

Conclusions

These results suggest that working memory training promotes endogenous BDNF but does not alter drug-seeking or drug-taking behavior. However, individual differences in cognitive performance prior to drug exposure may predict vulnerability to future drug use.

Neural underpinnings of response inhibition in substance use disorders: weak meta-analytic evidence for a widely used construct

RATIONALE

Substance use disorders (SUDs) rank among the most severely debilitating psychiatric conditions. Among others, decreased response inhibition capacities could make it more difficult for patients to abstain from drug use and maintain abstinence. However, meta-analyses on the neural basis of response inhibition in SUDs yielded conflicting results.

OBJECTIVE

In this study, we revisited the neuroimaging research field and summarized the existing fMRI literature on overt response inhibition (Go/NoGo and stop-signal paradigms) across different SUDs.

METHODS

We performed a systematic literature review and an activation likelihood estimation (ALE) meta-analysis to investigate the actual convergence of functional deviations observed in SUD samples. Results were further supplied by consecutive robustness measures and a post-hoc random-effects meta-analysis of behavioural data.

RESULTS

We identified k = 21 eligible studies for our analysis. The ALE analysis indicated a significant cluster of convergence with its statistical peak in the right anterior insula. Consecutive analyses, however, indicated this result was not robust and susceptible towards publication bias. Additionally, a post-hoc random effects meta-analysis of the behavioural parameters of Go/NoGo and stop-signal paradigms reported by the included studies revealed no significant differences in task performance comparing SUD samples and controls.

CONCLUSION

We discuss that the role of task-based response inhibition may require some refinement as an overarching marker for SUD pathology. Finally, we give a few prospects for future research that should be further explored in this context.

Be more mindful: Targeting addictive responses by integrating mindfulness with cognitive bias modification or cue exposure interventions

This review provides an overview of the most prominent neurocognitive effects of cognitive bias modification (CBM), cue-exposure therapy and mindfulness interventions for targeting addictive responses. It highlights the key insights that have stemmed from cognitive neuroscience and brain imaging research and combines these with insights from behavioural science in building a conceptual model integrating mindfulness with response-focused CBM or cue-exposure interventions. This furthers our understanding of whether and how mindfulness strategies may i) facilitate or add to the induced response-focused effects decreasing cue-induced craving, and ii) further weaken the link between craving and addictive responses. Specifically, awareness/monitoring may facilitate, and decentering may add to, response-focused effects. Combined awareness acceptance strategies may also diminish the craving-addiction link. The conceptual model presented in this review provides a specific theoretical framework to deepen our understanding of how mindfulness strategies and CBM or cue-exposure interventions can be combined to greatest effect. This is important in both suggesting a roadmap for future research, and for the further development of clinical interventions.

A randomized, parallel group, pragmatic comparative-effectiveness trial comparing medication-assisted treatment induction methods in primary care practices: The HOMER study protocol

Opioid use disorder (OUD) represents a public health crisis in the United States. Medication for opioid use disorder (MOUD) with buprenorphine in primary care is a proven OUD treatment strategy. MOUD induction is when patients begin withdrawal and receive the first doses of buprenorphine. Differences between induction methods might influence short-term stabilization, long-term maintenance, and quality of life. This paper describes the protocol for a study designed to: (1) compare short-term stabilization and long-term maintenance treatment engagement in MOUD in patients receiving office, home, or telehealth induction and (2) identify clinically-relevant practice and patient characteristics associated with successful long-term treatment. The study design is a randomized, parallel group, pragmatic comparative effectiveness trial of three care models of MOUD induction in 100 primary care practices in the United States. Eligible patients are at least 16 years old, have been identified by their clinician as having opioid dependence and would benefit from MOUD. Patients will be randomized to one of three induction comparators: office, home, or telehealth induction. Primary outcomes are buprenorphine medication-taking and illicit opioid use at 30, 90, and 270 days post-induction. Secondary outcomes include quality of life and potential mediators of treatment maintenance (intentions, planning, automaticity). Potential moderators include social determinants of health, substance use history and appeal, and executive function. An intent to treat analysis will assess effects of the interventions on long-term treatment, using general/generalized linear mixed models, adjusted for covariates, for the outcomes analysis. Analysis includes practice- and patient-level random effects for hierarchical/longitudinal data. No large-scale, randomized comparative effectiveness research has compared home induction to office or telehealth MOUD induction on long-term outcomes for patients with OUD seen in primary care settings. The results of this study will offer primary care providers evidence and guidance in selecting the most beneficial induction method(s) for specific patients.

Cognitive training and remediation interventions for substance use disorders: a Delphi consensus study

AIMS

Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions.

DESIGN, SETTING AND PARTICIPANTS

We used a Delphi approach with two sequential phases: survey development and iterative surveying of experts. This was an on-line study. During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n = 54) identified via recommendations from the Steering Committee and a systematic review.

MEASUREMENTS

Survey with 67 items covering four key areas of intervention development: targets, intervention approaches, active ingredients and modes of delivery.

FINDINGS

Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias modification, goal-setting, strategy learning and meta-awareness as active ingredients; and (iv) both addiction treatment work-force and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities.

CONCLUSIONS

Expert recommendations on cognitive training and remediation for substance use disorders highlight the relevance of targeting implicit biases, reward, emotion regulation and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.

Post-error slowing predicts for relapse in individuals with alcohol use disorder

BACKGROUND

Relapse characterizes addiction. The cognitive phenotype underlying relapse in individuals with alcohol use disorder (AUD) remain unelucidated. Here we aimed to investigate the potential changes in behavioral adjustment in AUD, and the association with relapse.

METHOD

Forty-seven subjects with AUD at Shandong Mental Health Center completed the stop-signal task, the PACS, the Beck Depression Inventory and the State-Trait anxiety questionnaires. Thirty age-matched male healthy subjects served as the control group (HC). In the follow-up, twenty-one subjects remained abstinent, while twenty-six subjects relapsed. Independent sample t-test was applied to measure differences between two groups and logistic regression analysis was conducted to explore the potential predictors on relapse.

RESULTS

The results showed that there were significant differences in stop signal reaction time (SSRT) and trigger failure between the AUD and HC groups. Relapsed group showed longer post-error slowing (PES) when compared to the non-relapsed group. The PES could predict relapse in alcohol use disorder.

CONCLUSION

Individuals with AUD showed impaired inhibitory control, which may predict relapse.

Alcohol-specific inhibition training in patients with alcohol use disorder: a multi-centre, double-blind randomized clinical trial examining drinking outcome and working mechanisms

AIMS

For the first time, to our knowledge, in a clinical sample with alcohol use disorder (AUD), this study compared the effects of two versions of alcohol-specific inhibition training (Alc-IT) on drinking outcomes and on experimental parameters assessing two possible working mechanisms: stimulus devaluation and inhibitory enhancement.

DESIGN

Multi-centre, double-blind, three-arm clinical RCT with 3-, 6- and 12-month follow-up comparing standard Alc-IT, improved Alc-IT and an active control condition.

SETTING

Three specialized AUD treatment centres in Switzerland.

PARTICIPANTS

A total of 242 detoxified, recently abstinent patients with severe AUD (18-60 years; 29.8% female).

INTERVENTION AND COMPARATOR

Both interventions [standard Alc-IT (n = 84) and improved Alc-IT (n = 79)] and the comparator [unspecific inhibition training (n = 79)] consisted of six sessions of a modified inhibitory task (Go/NoGo task) with alcohol-related and neutral stimuli. Both versions of Alc-IT required response inhibition in alcohol-related trials but differed in Go/NoGo ratios (standard: 50/50; improved: 75/25), with improved Alc-IT posing higher inhibitory demands. The control condition, an unspecific inhibition training, featured alcohol-related pictures in Go as well as NoGo trials.

MEASUREMENTS

The primary outcome, percentage of days abstinent, was assessed at 3-month follow-up with a time-line follow-back interview.

FINDINGS

The group receiving improved Alc-IT showed a significantly higher percentage of days abstinent at 3-month follow-up compared with the control group [γ_control  = 74.30; γ_improved  = 85.78; β = 11.48, 95% confidence interval (CI) = 2.57, 20.40, P = 0.012, adjusted r²  = 0.062], while for standard Alc-IT no effect significantly different from zero was detected (γ_standard  = 70.95; β = -3.35, 95% CI = -12.20, 5.50, P = 0.457, adjusted r²  = -0.04).

CONCLUSIONS

Alcohol-specific inhibition training with high inhibitory demands increased days abstinent at 3-month follow-up in patients with severe alcohol use disorder. Such an improved, inhibitory-demanding, alcohol-specific inhibition training outperformed the standard version of alcohol-specific inhibition training, suggesting an inhibitory working mechanism.

Early Improvement of Neuropsychological Impairments During Detoxification in Patients with Alcohol Use Disorder

AIMS

To assess recovery of alcohol-related neuropsychological deficits in a group of patients with pure severe alcohol use disorder (AUD) during a detoxification program using the Brief Evaluation of Alcohol-Related Neuropsychological Impairment (BEARNI) test.

METHODS

Thirty-two patients with severe AUD using DSM-IV criteria (24 men, mean age = 45.5 ± 6.8 years old) were assessed using the BEARNI 8 ± 2 days after alcohol cessation (T1) and then were reassessed within 18 ± 2 days after alcohol cessation (T2). The primary study endpoint was the number of patients initially impaired at T1 who recovered cognitive functions at T2 assessment.

RESULTS

At T1, 59% (n = 19) patients with pure severe AUD had at least one impaired cognitive function assessed by the BEARNI. At T2, 63% of the patients with AUD with deficits at T1 had normal BEARNI cognitive scores (χ2 = 7.7, P = 0.005); specifically, the percentages of participants with normal subtest scores were 63% on memory (χ2 = 12.4, P = 0.0004), 100% on verbal fluency (χ2 = 16; P = <0.0001), 60% on alphabetical span (χ2 = 12.8; P = 0.0003) and 67% on visuospatial (χ2 = 15, P = 0.0001).

CONCLUSIONS

The cognitive impairments of two-thirds of patients with pure AUD included in the present study recovered within 18 days of abstinence, earlier than reported in previous studies.

Plasma Concentrations of Neurofilament Light Chain Protein and Brain-Derived Neurotrophic Factor as Consistent Biomarkers of Cognitive Impairment in Alcohol Use Disorder

For a long time, Substance Use Disorders (SUDs) were not considered a component in the etiology of dementia. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders introduced substance-induced neurocognitive disorders, incorporating this notion to clinical practice. However, detection and monitoring of neurodegenerative processes in SUD patients remain a major clinical challenge, especially when early diagnosis is required. In the present study, we aimed to investigate new potential biomarkers of neurodegeneration that could predict cognitive impairment in SUD patients: the circulating concentrations of Neurofilament Light chain protein (NfL) and Brain-Derived Neurotrophic Factor (BDNF). Sixty SUD patients were compared with twenty-seven dementia patients and forty healthy controls. SUD patients were recruited and assessed using the Psychiatric Research Interview for Substance and Mental (PRISM) and a battery of neuropsychological tests, including the Montreal Cognitive Assessment test for evaluation of cognitive impairment. When compared to healthy control subjects, SUD patients showed increases in plasma NfL concentrations and NfL/BDNF ratio, as well as reduced plasma BDNF levels. These changes were remarkable in SUD patients with moderate-severe cognitive impairment, being comparable to those observed in dementia patients. NfL concentrations correlated with executive function and memory cognition in SUD patients. The parameters "age", "NfL/BDNF ratio", "first time alcohol use", "age of onset of alcohol use disorder", and "length of alcohol use disorder diagnosis" were able to stratify our SUD sample into patients with cognitive impairment from those without cognitive dysfunction with great specificity and sensibility. In conclusion, we propose the combined use of NfL and BDNF (NfL/BDNF ratio) to monitor substance-induced neurocognitive disorder.

The Treatment of Substance Use Disorders: Recent Developments and New Perspectives

Substance-related disorders are complex psychiatric disorders that are characterized by continued consumption in spite of harmful consequences. Addiction affects various brain networks critically involved in learning, reward, and motivation, as well as inhibitory control. Currently applied therapeutic approaches aim at modification of behavior that ultimately leads to decrease of consumption or abstinence in individuals with substance use disorders. However, traditional treatment methods might benefit from recent neurobiological and cognitive neuroscientific research findings. Novel cognitive-behavioral approaches in the treatment of addictive behavior aim at enhancement of strategies to cope with stressful conditions as well as craving-inducing cues and target erroneous learning mechanisms, including cognitive bias modification, reconsolidation-based interventions, mindfulness-based interventions, virtual-reality-based cue exposure therapy as well as pharmacological augmentation strategies. This review discusses therapeutic strategies that target dysregulated neurocognitive processes associated with the development and maintenance of disordered substance use and may hold promise as effective treatments for substance-related disorders.

The Use of Smartphone Serious Gaming Apps in the Treatment of Substance Use Disorders: Observational Study on Feasibility and Acceptability

Background

Addiction is a worldwide problem with major health complications. Despite intensive treatment, relapse rates remain high. The prevalence of cognitive impairment is high in patients with substance use disorders (SUDs) and is associated with treatment dropout and relapse. Evidence indicates that cognitive function training in persons with SUDs may support treatment. Therefore, the use of web-based tools to test and train cognitive functions is of increasing interest.

Objective

The goal of this study was to determine the feasibility and acceptability of a serious gaming smartphone app to test and train cognitive functions in addition to the treatment of SUDs.

Methods

A prospective observational study was conducted with 229 patients seeking addiction treatment. The patients were offered 2 smartphone apps in addition to regular care: MyCognition Quotient (MyCQ) assessed cognitive functions and AquaSnap trained these functions. The feasibility was determined based on acceptance rates. The acceptability of the smartphone apps was qualitatively analyzed based on the answers to a questionnaire. Patient characteristics were compared between patients who played and did not play smartphone games. Explorative correlation analyses were performed between the playing time and cognitive assessment scores.

Results

Of the 229 patients who were offered the apps, 110 completed the MyCQ assessment, and 59 started playing AquaSnap, yielding acceptance rates of 48.0% and 25.8%, respectively. The group that completed the MyCQ assessment was significantly more educated than the group that did not download the apps (χ²₂=7.3; P=.03). The education level did not differ significantly between the group that played AquaSnap and the group that did not (P=.06). There were relatively more women in the AquaSnap playing group than in the nonplaying group (χ²₁=6.5; P=.01). The groups did not differ in terms of age, substance use, treatment setting, mood, or quality of life. With respect to acceptability, 83% (38/46) of the patients who filled out the questionnaire enjoyed taking the MyCQ measurement, whereas 41% (14/34) enjoyed playing the AquaSnap game. Furthermore, 76% (35/46) and 68% (23/34) rated the apps MyCQ and AquaSnap, respectively, as easy. More playing minutes was associated with decreased working memory reaction time and executive functioning accuracy.

Conclusions

Our study showed that the use of a smartphone app for cognitive assessment in patients with SUDs who are interested and highly educated is feasible and acceptable for the subgroup that was asked to fill out a perception questionnaire. However, the use of a smartphone app for cognitive training was less feasible for this group of patients. Improvement of the training application and enhancement of the motivation of clients are needed. Despite these limitations, the present results provide support for future research investigating the use of smartphone apps for cognitive assessment and training in relation to the treatment of SUDs.

The role of attention control in complex real-world tasks

Working memory capacity is an important psychological construct, and many real-world phenomena are strongly associated with individual differences in working memory functioning. Although working memory and attention are intertwined, several studies have recently shown that individual differences in the general ability to control attention is more strongly predictive of human behavior than working memory capacity. In this review, we argue that researchers would therefore generally be better suited to studying the role of attention control rather than memory-based abilities in explaining real-world behavior and performance in humans. The review begins with a discussion of relevant literature on the nature and measurement of both working memory capacity and attention control, including recent developments in the study of individual differences of attention control. We then selectively review existing literature on the role of both working memory and attention in various applied settings and explain, in each case, why a switch in emphasis to attention control is warranted. Topics covered include psychological testing, cognitive training, education, sports, police decision-making, human factors, and disorders within clinical psychology. The review concludes with general recommendations and best practices for researchers interested in conducting studies of individual differences in attention control.

Effects of arousal modulation via resonance breathing on craving and affect in women with substance use disorder

BACKGROUND

Craving for alcohol and other drugs is a complex in-the-moment experience that involves within-person changes in physiological arousal and affect. We evaluated the utility of a just-in-time, self-administered resonance breathing smartphone application (app) to reduce craving and improve affect in women during outpatient treatment for substance use disorders (SUD).

METHODS

Women (N = 57) receiving outpatient addiction treatment were randomized to practice either cardiovascular resonance breathing (0.1 Hz/6 breaths per minute) or a sham (∼0.23 Hz/14 breaths per minute) in the face of urges over an 8-week intervention. Craving (Penn Alcohol Craving Scale) and affect (Positive and Negative Affect Scale) were collected weekly throughout the intervention. App data were uploaded weekly to assess frequency of use. Generalized Estimated Equations modeled craving and affect as a function of group randomization and app use frequency across the 8-week intervention.

FINDINGS

Higher levels of craving were associated with more frequent app use. The group X app use interaction was significant for craving. Frequent app use during the intervention phase was associated with lower craving levels in the resonance breathing group relative to the sham group over the 8-week intervention. There was no effect of app use frequency on affect measures.

CONCLUSIONS

Women assigned to practice sham breathing who used the intervention frequently experienced elevations in craving that are commonly reported during outpatient SUD treatment. Women assigned to resonance breathing who used the intervention frequently did not experience such increases. Resonance breathing may be protective against triggers in outpatient treatment. Physiological mechanisms are discussed.

Reactive and Regulative Temperament in Relation to Clinical Symptomatology and Personality Disorders in Patients with a Substance Use Disorder

Temperament and personality traits are important factors underlying the vulnerability for both the initiation and continuation of addictive behaviors. We investigated the influence of reactive and regulative temperament and their interaction in relation to clinical symptomatology and personality disorders (PDs) in a sample of 841 inpatients (68.1% males) with a substance use disorder (SUD). To assess reactive temperament we used the Behavioral Inhibition and Behavioral Activation Scales (BISBAS) and to assess regulative temperament we used the Effortful Control Scale. Clinical symptomatology and personality traits were measured by means of the Symptom Checklist-90 (SCL-90) and the Assessment of ADP-IV Personality Disorders (ADP-IV). Hierarchical regression analyses showed that both, clinical symptomatology and PDs were related to low levels of effortful control (EC). None of the two-way interactions (BIS × EC, BAS × EC) however were significantly related to psychopathology. Current findings highlight the role of effortful control (EC) in the expression of psychopathology in an adult sample of inpatients with SUD. Therapeutic interventions aiming at strengthening EC can possibly result in better treatment outcomes for both the addiction and the comorbid psychopathology.

Efficacy of the Therapeutic Game "Trisquel" in the Treatment of Patients With Substance-Related Disorders Randomized Clinical Study

Substance-related disorders (SRD) have been consistently associated with alterations both in cognitive and executive functions, which affect to patients' quality of life. The main objective of this work was to test the beneficial cognitive effects on patients with SRD after the implementation of "Trisquel," an intervention program in board game format. To check the effectiveness of Trisquel program, a group of people diagnosed with SRD was randomly assigned either to the experimental group or to the control group. The experimental group performed Trisquel structured sessions twice a week during 3 months, while the control group performed routinely conventional therapeutic activities with the same frequency and duration. Neuropsychological tests were done to both groups before and after the intervention. After the 3 months of intervention the experimental group showed the following statistically significant improvements for WAIS-III subtests: number key, symbol search, arithmetic, direct digits, inverse digits, total digits, letters-numbers in the processing speed index and in the working memory index. Regarding STROOP tests, statistically significant progress was observed in the phonetic fluency letter P, phonetic fluency letter M, phonetic fluency letter R subtests, word-reading and word-color subtests. The control group only obtained improvements for WAIS-III subtests of arithmetic, letters-numbers and in the working memory index. The results of this study confirm that "Trisquel" is an effective intervention program for people diagnosed with SRD, getting improvements in processing speed (psychomotor and reading), attentional subprocesses (focused and sustained) and executive functions (updating and inhibition).

Distress-driven impulsivity interacts with trait compulsivity in association with problematic drinking: A two-sample study

OBJECTIVE

Problematic drinking is highly prevalent among the general population, oftentimes leading to significant negative consequences, including physical injury, psychological problems and financial hardship. In order to design targeted early interventions for problematic drinking, it is important to understand the mechanisms that render individuals at risk for and/or maintain this behavior. Two candidate drivers of problematic drinking are distress-driven impulsivity and trait compulsivity, with recent research suggesting these constructs may interact to enhance risk for addictive behaviors. The current study examined whether individual differences in distress-driven impulsivity and trait compulsivity interact in relation to problematic drinking.

METHOD

Distress-driven impulsivity (indexed by the S-UPPS-P negative urgency subscale), trait compulsivity (indexed by the CHIT scale) and problematic drinking (indexed by the BATCAP alcohol scale) were assessed in two independent online samples (Sample 1, n = 117; Sample 2, n = 474). Bootstrapped moderation analysis was conducted to examine whether trait compulsivity moderated the relationship between distress-driven impulsivity and problematic drinking.

RESULTS

In both samples, there was a significant interaction between distress-driven impulsivity and trait compulsivity in relation to problematic drinking. Follow-up tests revealed that, in both samples, higher distress-driven impulsivity was associated with more problematic drinking behaviors among participants with high trait compulsivity only.

CONCLUSIONS

The current findings add to the growing literature supporting an interactive relationship between impulsivity and compulsivity-related traits in relation to addictive behaviors and have implications for informing early detection of risk and targeted early interventions.

Substance use disorder and obesogenic eating: Does working memory training strengthen ability to abstain from unwanted behaviors? A systematic review

INTRODUCTION

Abstaining from unwanted behaviors requires a sufficient balance between the executive and impulsive cognitive systems. Working memory (WM) is a vital component of both systems, identified in a wide range of research as the central and dominant component of executive function. WM potentially modulates the desires, tendencies, and behaviors specific to and seen in individuals with substance use disorder (SUD) and obesogenic eating (OE). Compared to healthy populations, research has shown individuals with SUD, as well as those who display OE, to have some degree of executive dysfunction, and both conditions have far-reaching health care implications. Additionally, these deficits are associated with impulsive behavior. Research has proposed that impulsive and so-called reward-driven responses could be altered through cognitive therapy and that both SUD and OE could benefit from working memory training (WMT).

METHOD

In this narrative review, we systematically align extant empirical reasoning and evidence with these assumptions. Our main aim is to ascertain and summarize the value of WMT for the treatment of both SUD and food reward consummatory behaviors. As a means to include detailed narrative accounts of all papers of potential value, our thresholds for meaningful improvements in both WM and unwanted behaviors are broad.

RESULTS

The results from the eleven qualifying studies are as follows: Nine of ten studies show a significant positive training effect of WMT on one or more components of WM capacity; three of six eligible papers (two on alcohol and one on opioid addiction) deliver notable improvements in SUD in response to WMT. One of two suitable studies showed WMT to be a moderately efficacious form of therapy for OE. Conversely, WMT appears to have negligible therapeutic benefit for cognitive function deficits or psychopathology unrelated to WM, suggesting that WMT has unique treatment efficacy for impulsive human behaviors.

CONCLUSION

In conclusion, more rigorous and uniform studies on WMT and impulsive harmful behaviors are required to give proof of the benefits of this potential useful treatment.

Cognitive Training Effectiveness on Memory, Executive Functioning, and Processing Speed in Individuals With Substance Use Disorders: A Systematic Review

Background: Cerebral neuroplasticity is compromised due to substance abuse. There is damage to neuronal areas that are involved in memory and executive functioning. Treatments with worse outcomes are often associated with cognitive deficits that have resulted from substance dependence. However, there is evidence that cognitive training can lead to improvements in cognitive functions and can be useful when treating addictions. This systematic review aims to synthesize evidence on the effectiveness of cognitive training in memory, executive functioning, and processing speed in individuals with substance use disorder (SUD).

Methods: The Joanna Briggs Institute's PICO strategy was used to develop this systematic literature review. Four databases were searched (PubMed, the Cochrane Library, Web of Science, and PsycINFO) to identify controlled randomized clinical studies and quasi-experimental studies, in English, Portuguese, and Spanish, from 1985 to 2019. The literature found was examined by two independent reviewers, who assessed the quality of studies that met the inclusion criteria. The Cochrane risk-of-bias tool for the randomized controlled trials and the ROBINS-I tool for non-randomized studies were used to assess the risk of bias. In data extraction, the Cochrane Handbook for Systematic Reviews was considered.

Results: From a total of 470 studies, 319 were selected for analysis after the elimination of duplicates. According to the inclusion criteria defined, 26 studies were eligible and evaluated. An evaluation was performed considering the participant characteristics, countries, substance type, study and intervention details, and key findings. Of the 26 selected studies, 14 considered only alcoholics, six included participants with various SUD (alcohol and other substances), three exclusively looked into methamphetamine-consuming users and another three into opioid/methadone users. Moreover, 18 studies found some kind of cognitive improvement, with two of these reporting only marginally significant effects. One study found improvements only in measures similar to the training tasks, and two others had ambiguous results.

Conclusions: The included studies revealed the benefits of cognitive training with regard to improving cognitive functions in individuals with SUD. Memory was the most scrutinized cognitive function in this type of intervention, and it is also one of the areas most affected by substance use.

Systematic Review Registration: [PROSPERO], identifier [CRD42020161039].

Baseline executive functions and receiving cognitive rehabilitation can predict treatment response in people with opioid use disorder

BACKGROUND

Impaired cognitive functions, particularly executive function, predicts poor treatment success in people with substance use disorders. The current study investigated the effect of receiving adjunct cognitive rehabilitation and baseline executive function (EF) measures on treatment response among people with opioid use disorder (OUD).

METHOD

The analysis sample consisted of 113 participants with OUD who were discharged from a compulsory court-mandated methadone maintenance treatment (MMT) and followed for 3 months. We used the Backward digit span/Auditory verbal learning, Stroop, and Trail making tests to assess the three measures of EF, including working memory, inhibition, and shifting, respectively. Treatment response was operationalized as (1) treatment retention and (2) the number of positive urine tests for morphine during 3-month follow-up periods. The study used Cox's proportional hazards model and linear mixed model to identify predictive factors.

RESULTS

Lower Stroop interference scores predicted increased length of stay in treatment (χ² = 33.15, P < 0.001). The linear mixed model showed that scores on auditory verbal learning test and group intervention predicted the number of positive urine tests during a 3-month follow-up.

CONCLUSION

Working memory and inhibitory control, as well as receiving cognitive rehabilitation, could be potentially considered as predictors of treatment response for newly MMT admitted patients with OUD. Assessment of EF before treatment initiation may inform treatment providers about patient's cognitive deficits that may interfere with therapeutic interventions.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

Web-Based Cognitive Training to Improve Working Memory in Persons with Co-Occurring HIV Infection and Cocaine Use Disorder: Outcomes from a Randomized Controlled Trial

Neurocognitive impairment (NCI) remains a persistent complication of HIV disease that nearly half of persons with HIV experience, and rates are even higher in persons who use substances such as cocaine. Cognitive training is a promising intervention for HIV-associated NCI. In this randomized controlled trial, we examined the feasibility and effectiveness of a web-based cognitive training program to improve working memory in a sample of 58 persons with HIV and cocaine use disorder. Participants were randomly assigned to either the experimental working memory training arm or the attention control training arm and completed up to 48 daily sessions over 10 weeks. Overall, treatment completion (74%) and retention rates (97%) were high, and participant feedback indicated the intervention was acceptable. Our results show that the intervention successfully reduced working memory deficits in the experimental arm relative to the control arm. Our findings support both the feasibility and effectiveness of cognitive training in this population.

Cognitive Remediation as an Adjunct Treatment for Substance Use Disorders: A Systematic Review

Substance use disorders are associated with diverse neuropsychological impairments, with deficits in memory and executive functioning commonly observed. Cognitive remediation has been shown to be effective in other populations with cognitive impairments in these domains, including those with psychiatric disorders and acquired brain injuries, and it has been hypothesised to be similarly effective for those in treatment for substance use disorders. We aimed to systematically review the evidence for cognitive remediation interventions administered as an adjunct treatment to substance use rehabilitation. Studies were included if participants were receiving substance use treatment, if improving cognitive functioning was the main focus of the intervention and if they used an experimental design with a control condition receiving treatment-as-usual or an active control intervention. Two independent reviewers agreed on the final selection of 32 studies, encompassing cognitive remediation for working memory, memory, executive functioning and general cognition. Significant differences between intervention and control groups for cognitive test results and treatment outcomes were extracted and compared across treatment approaches. The review found considerable heterogeneity across studies, including in the types of interventions, the nature of participants and the outcome measures used. Further, a lack of quality studies with sufficient power meant that limited conclusions could be drawn, highlighting a need for further replication and research. However, findings indicate that cognitive remediation remains a promising potential avenue for improving cognition and treatment outcomes for those in treatment for substance use disorders. Protocol submitted prospectively to PROSPERO 30.09.2019, CRD42020150978.

Altered intrinsic connectivity distribution in internet gaming disorder and its associations with psychotherapy treatment outcomes

Alterations in brain connectivity have been implicated in internet gaming disorder (IGD). However, little is known about alterations in whole-brain connectivity and their associations with long-term treatment outcomes. Here, we used a relatively new analytic approach, intrinsic connectivity distribution (ICD) analysis, to examine brain connectivity in 74 IGD participants and 41 matched healthy controls (HCs) and conducted post hoc seed-based resting-state functional connectivity (rsFC) analyses based on the ICD findings. We also examined how these findings related to outcomes involving a craving behavioral intervention (CBI) for IGD. IGD participants showed less whole-brain connectivity in the left angular gyrus and ventromedial prefrontal cortex (vmPFC) compared with HC participants. Seed-based rsFC analyses revealed that the left angular gyrus in the IGD group showed less connectivity with areas involved in the default-mode network and greater connectivity with areas in the salience and executive control networks. CBI was associated with improved connectivity within regions in the default-mode network and regions across the default-mode and salience networks. ICD-identified connectivity differences in the left angular gyrus and vmPFC were related to changes in craving and severity of addiction 6 months after the intervention. The findings suggest that IGD is associated with alterations in brain connectivity that may be sensitive to interventions. Thus, the findings have implications for understanding mechanisms underlying CBI effects and for further treatment development.

A systematic review and meta-analysis on the clinical implications of probability discounting among individuals with Internet gaming disorder

The significance of probability discounting (PD) among individuals with Internet gaming disorder (IGD) remains unclear. Following the PRISMA guidelines, we systematically searched the PubMed, Embase, and ScienceDirect databases for English articles on Internet addiction that included comparison between individuals with and without IGD as well as probabilistic discounting task as the main outcome from January 1970 to July 2020 using the appropriate keyword strings. The primary outcome was the overall difference in rate of PD, while the secondary outcomes included the difference in PD with magnitude of probabilistic reward and response time of the PD task. Effect size (ES) was calculated through dividing the group means (e.g., h value or AUC) by the pooled standard deviations of the two groups. A total of five studies with 300 participants (i.e., IGD group, n = 150, mean age = 20.27 ± 2.68; healthy controls, n = 150, mean age = 20.70 ± 2.81) were analyzed. The IGD group was more willing to take risks in probabilistic gains but performances on probabilistic losses were similar between the two groups. The IGD group also exhibited a shorter response time (Hedge's g = - 0.51; 95%CI = - 0.87 to - 0.15). Meta-regression demonstrated a positive correlation between maximum reward magnitude and PD rate (p < 0.04). However, significant publication bias was noted among the included studies (Egger's test, p < 0.01). In conclusion, individuals with IGD seemed more impulsive in making risky decisions, especially when the potential gains were expected. Our findings not only supported the use of PD for assessing individuals with IGD but may also provide new insights into appropriate interventions.

The transcranial direct current stimulation over prefrontal cortex combined with the cognitive training reduced the cue-induced craving in female individuals with methamphetamine use disorder: A randomized controlled trial

BACKGROUND

Craving and cognitive deficits are potential treatment targets for methamphetamine use disorder (MUD). Previous studies implied that transcranial direct current stimulation (tDCS) and cognitive training respectively improve these symptoms, but the combined effect is unknown. In this study, we investigated the combined effects of tDCS over dorsolateral prefrontal cortex (DLPFC) and computerized cognitive addiction therapy (CCAT) on cue-induced craving and cognitive functions among female individuals with MUD.

METHODS

Seventy-five patients with MUD were randomly assigned to three groups: CCAT + tDCS group, CCAT + sham tDCS group and the control group. The former two groups received 20 sessions of cognitive training combined 1.5 mA active/sham tDCS over DLPFC (20min/session, 5times/week), while the control group received usual care which includes routine medical care, health education, physical exercises and psychological support related to relapse prevention. The cue-induced craving and cognitive functions were tested at the baseline, the end of 2nd week and 4th week.

RESULTS

The CCAT + tDCS group showed a significant reduction in cue-induced craving after 4-week intervention. Moreover, the craving score of the real CCAT + tDCS group was significantly lower than that of the CCAT + sham tDCS group and that of the control group at the end of 4th week. A significant improvement in accuracy of TWOB task was only observed in the CCAT + tDCS group at the end of 4th week when compared to baseline. Unexpectedly, participants who received CCAT plus active or sham tDCS did not change their discounting, whereas those in the control group performed more impulsively over time.

CONCLUSIONS

The study found that the intervention of tDCS over DLPFC combined with CCAT may have potential benefit in improving treatment outcome in patients with MUD. More research is needed to explore the underlying mechanism.

Tackling heterogeneity: Individual variability of emotion decoding deficits in severe alcohol use disorder

BACKGROUND

Severe alcohol use disorder (SAUD) is associated with social cognition deficits. Patients with SAUD are impaired for the recognition of emotional facial expressions, particularly at early stages of abstinence. These deficits damage interpersonal relations and increase relapse risk. However, uncertainties still abound on their variation across emotions and on the heterogeneity of emotional impairments across patients. We addressed these questions by exploring how the deficit varies according to emotions' type/intensity and patients' heterogeneity.

METHODS

Sixty-five recently detoxified patients with SAUD and 65 matched healthy controls performed the Facial Emotion Recognition Test, assessing the ability to identify six emotions (anger, contempt, disgust, fear, happiness, sadness) displayed by morphed faces with various intensities. Accuracy scores and detection thresholds were collected for each emotion. Beyond group comparisons, multiple single-case analyses determined the percentage of patients presenting decoding deficits for each emotion.

RESULTS

When current depression and anxiety symptoms were controlled for, patients did not present a general emotion decoding deficit, but were rather characterized by specific deficits for disgust/contempt in accuracy, and for disgust in detection threshold scores. Single-case analyses showed that only a third of patients presented a clinically significant emotional deficit.

CONCLUSIONS

Patients with SAUD only present emotional decoding deficits for specific interpersonal emotions (disgust/contempt) when subclinical psychopathological states are controlled for, and show no general emotional impairment. This goes against the proposal of a generalized social cognition deficit in this population. This group effect moreover masks a massive heterogeneity across patients, which has implications at experimental and clinical levels.

High Trait Attention Promotes Resilience and Reduces Binge Drinking Among College Students With a Family History of Alcohol Use Disorder

Binge patterns of alcohol use among post-high school emerging adults are associated with both immediate negative consequences and increased risk of long-term drinking problems, particularly among individuals with a family history (FH) of alcohol use disorder (AUD). Therefore, the developmental time period of emerging adulthood, paired with the high-risk environment of college campuses, represents an important target for interventions. Attentional ability has recently emerged as a mediator of resilience to stress-related psychopathology and offers a potential neurocognitive target for interventions. We tested the hypothesis that attentional ability promotes resilience to binge drinking in a sample of 464 college students with (n = 221) or without (n = 243) familial risk for AUD. Two-way analyses of covariance (ANCOVA) tested effects of FH and self-reported binge drinking on attention scores from the Barratt Impulsiveness Scale (BIS). In addition, mediation analyses tested whether BIS attention scores mediated the relationship between Conner-Davidson Resilience Scale scores and binge drinking. ANCOVA results indicated a significant FH-by-binge drinking interaction (p = 0.008) in which FH positive subjects who did not binge drink had the fewest attention problems, consistent with a marker of resilience. Furthermore, BIS attention scores significantly mediated the effect of Conner-Davidson Resilience Scale scores on binge drinking, with stronger effects in FH positive subjects (p < 0.001) than FH negative subjects (p = 0.49). The findings suggest that attention promotes resilience to binge drinking in individuals with familial risk for AUD. Interventions targeting attentional ability in this high-risk population, particularly FH positive individuals with attention deficits, may serve to reduce binge drinking and its consequences.

Evidence That Implementation Intentions Enhance Cognitive Training and Reduce Alcohol Consumption in Heavy Drinkers: A Randomized Trial

BACKGROUND

Current training tasks to improve the cognitive deficits thought to be involved in sustained heavy drinking need further investigation to optimize their effectiveness.

PURPOSE

The present study investigated whether combining implementation intention provision with a cognitive training task had a measurable effect on alcohol consumption in heavy drinkers and explored the neural mechanisms underpinning any reductions in subsequent alcohol consumption.

METHODS

Thirty-two heavy-drinking participants completed approach-avoidance and visual probe training tasks preintervention and postintervention during functional Magnetic Resonance Imaging. Participants in the intervention group were randomized to form implementation intentions and participants in the control condition read a goal intention. Alcohol consumption was recorded preintervention and at 1 month follow-up.

RESULTS

Compared to the control group, implementation intention provision significantly improved performance on alcohol-avoidance tasks postintervention, t(30) = -2.315, p = .028, d = .85, and reduced alcohol consumption by 6.9 units/week (1 unit = 10 mL or 8 g ethanol), F(1,30) = 4.263, p = .048 (d = .74), at follow-up. However, the analysis of functional Magnetic Resonance Imaging data revealed no significant differences between groups.

CONCLUSIONS

These findings show for the first time that implementation intentions targeting cognitive processes can significantly reduce alcohol consumption among heavy drinkers. However, there was no evidence that the effects were mediated by changes in neural activity. Further work is required to explore the neural mechanisms underpinning the operation of implementation intentions.

TRIAL REGISTRATION

This trial was registered (ISRCTN:35503634) and is available at https://www.isrctn.com/ISRCTN35503634.

Effects of working memory training on emotion regulation: Transdiagnostic review

Working memory training is widely used transdiagnostically to improve cognition. However, more recently, studies using working memory training packages have targeted emotion-regulation outcomes to determine whether far transfer effects can be achieved. A narrative review is conducted of studies that have used standardized computerized working memory training packages across healthy volunteers, affect, anxiety, post-traumatic stress disorder (PTSD), and eating disordered populations with emotion-regulation outcomes. Working memory training has been used in children, adolescents, and adults to improve emotion regulation. Many studies have reported gains in mood as well as emotion-regulation strategies following working memory training, regardless of clinical indication and whether near transfer gains were achieved in cognitive domains. Significant emotion-regulation outcomes include: state and trait anxiety, rumination, brooding, positive appraisal, decreasing maladaptive emotion-regulation strategies, and decreasing intrusive thoughts. It is speculated that these far transfer outcomes from working memory training are possible due to the cognitive and neural overlap between cognitive and affective working memory, and emotion regulation. Working memory training could improve cognitive efficiency, which, in turn, increases the availability of cognitive resources during times when emotion regulation is taxed. Future studies need to consider the role of participant expectancy in predicting outcome measure performance, and including subjective and objective outcomes is paramount to study design. Furthermore, sample sizes require additional attention, given that the current review highlights that individual differences in non-clinical and clinical populations influence the outcomes from working memory training. Working memory training offers a possibility for improving emotion regulation transdiagnostically.

Dispositional Disinhibition and Alcohol Use Disorders: Personality, Risk Appraisal and Problematic Alcohol Consumption

Background: The relationship between psychopathic personality and problematic alcohol consumption could be important for understanding risk and potential interventions. This existing work on psychopathy and alcohol abuse is typically conducted in criminal and hospitalized populations and little attention has been paid to investigating the general populations' psychopathic personality and problematic consumption of alcohol. The psychopathy-focused Triarchic Psychopathy Measure (TriPM) and the more general Reinforcement Sensitivity Theory of personality (RST) focus on individual differences related to low self-control and sensation seeking, and could relate to problematic alcohol consumption in non-forensic samples. The current study brings together RST and psychopathic personality traits to predict alcohol use disorders. We hypothesize that impulsivity and anxiety predict problematic alcohol consumption and related risk appraisal. Methods: We analyzed data from a sample of 349 general population participants who had completed measures of the TriPM, RST, alcohol use disorders (AUDIT), and their perceived negative outcomes of high risk behavior with the Cognitive Appraisal of Risky Events (CARE) measure. Results: We find some evidence that TriPM's disinhibition and RST's anxious personality traits relate to AUDIT scores. We find limited evidence that personality traits predict the negative appraisal of risky events, but alcohol use was related to increased perceptions of the negative outcomes of alcohol consumption. Conclusions: Overall this study shows that individual differences do relate to problematic alcohol consumption but not the appraisal of risks related to alcohol consumption. This has implications for the structuring of intervention for those at-risk of problematic consumption of alcohol.

Cognitive training as a component of treatment of alcohol use disorder: A review

OBJECTIVE

Cognitive training is an effective means of improving performance in a range of populations. Whether it may serve to facilitate cognitive recovery and longer-term outcomes in persons with alcohol use disorders (AUDs) is unclear. Here, we review historical and current literature and offer perspectives for model development and potential implementation.

METHOD

We considered a large literature regarding the nature of alcohol-related compromise, early efforts to clarify the nature of recovery and current models and methods underlying cognitive training paradigms. We then constructed a narrative review demonstrating evolving frameworks and empirical data informing the critical review of cognitive training methods as a means of mitigating compromise and facilitating functional outcomes.

RESULTS

Cognitive improvement with abstinence is generally noted, but training protocols may enhance performance and generalize benefit to untrained, but highly similar, tasks. Transfer of training to dissimilar tasks and functional outcomes is uncommonly reported. It is noteworthy that some work suggests that clinician ratings for participants are improved. Inconsistency in sample characteristics, training protocols, and outcome measures constrain general conclusions while suggesting opportunities for study and development.

CONCLUSIONS

Cognitive training protocols have shown benefit in a variety of populations but have been examined infrequently in persons with AUDs. This overview indicates significant opportunity for cognitive improvement and recovery and thus a strong potential role for training protocols. However, supportive data are not robustly obtained. We suggest that one step in bridging this gap is the implementation of a conceptual framework incorporating contextual, behavioral, and neurobiological variables. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Inhibitory-control training for cocaine use disorder and contingency management for clinic attendance: A randomized pilot study of feasibility, acceptability and initial efficacy

BACKGROUND

Cocaine abusers have impaired inhibitory Cocaine use is associated with impaired inhibitory control. This study determined the feasibility, acceptability, and initial efficacy of inhibitory-control training to cocaine or neutral images in cocaine use disorder patients.

METHODS

Participants were randomly assigned to inhibitory-control training to cocaine (N = 20) or neutral (N = 20) images. Feasibility was assessed by percent of patients eligible for participation after a behavioral qualification session, time-to-target enrollment, percent of clinic visits attended, percent of participants who completed 80 % or more training sessions, and percent of follow-up visits attended. Acceptability was determined using a Treatment Acceptability Questionnaire. Initial efficacy was determined during training and a follow-up phase with urine samples tested qualitatively and quantitatively for cocaine. Participants in both conditions received monetary incentives delivered on an escalating schedule for clinic attendance.

RESULTS

The groups were well matched and no differences on demographic or substance use variables were observed. Attendance was stable during the treatment period with high overall attendance in both groups (average sessions attended: cocaine image group = 97 %; neutral image group = 90 %). No group differences were observed in the percentage of follow-up sessions attended (95 % for the cocaine-image group; 88 % of neutral-image group). Ratings on the Treatment Acceptability Questionnaire were high (i.e., mean scores ≥ 80 for all items rated on 101-unit visual analog scales). Participants in the cocaine- and neutral-image conditions did not differ significantly in terms of cocaine use during the training nor follow-up phase. Inhibitory-control training improved stop signal performance but not delay discounting.

CONCLUSION

The procedures were feasible and acceptable. Inhibitory-control training to cocaine images did not reduce cocaine use relative to the neutral image training condition. The inability to detect significant differences in cocaine use across the groups is not surprising given the small sample size. More research is needed to determine the utility of inhibitory-control training for cocaine use disorder. Future trials should determine whether inhibitory-control training to cocaine images augments the efficacy of other behavioral interventions.

Behavioral Treatments for Adolescent Cannabis Use Disorder: a Rationale for Cognitive Retraining

Purpose of Review

Adolescent cannabis use represents a significant public health concern. Cannabis experimentation typically begins in adolescence and increases the odds of meeting criteria for cannabis use disorder. Cannabis use disorder is associated with numerous short- and long-term adverse consequences for adolescents, highlighting the critical need for efficacious behavioral treatments. This brief review aims to synthesize the state of the behavioral treatment literature on adolescents with cannabis use disorder and to discuss new pathways to leverage neuroscience to inform novel targets for behavioral intervention.

Recent Findings

To date, effective treatment options for adolescent cannabis use disorder that have been tested in randomized controlled trials include cognitive behavioral therapy, motivational enhancement therapy, and multidimensional family therapy. However, established behavioral treatment approaches focus on higher-order cognitive control and have only been modestly effective.

Summary

There is a need to develop new pathways that translate neuroscience findings into novel targets for behavioral interventions.

Weaker Memory Performance Exacerbates Stress-Induced Cannabis Craving in Youths' Daily Lives

Theories of addiction posit that stimuli associated with drug use, including both exteroceptive (e.g., paraphernalia) and interoceptive (e.g., feeling tense or "stressed"), evoke craving and contribute to the pathogenesis of substance misuse. Control over drug cue response and stress is essential for moderating use. Building from laboratory data supporting associations between cue exposure, stress, and craving, this study tested whether these associations generalize to real-world settings and examined whether a well-vetted neurocognitive control capacity, i.e., working memory (WM), moderated associations. Youth (N = 85; 15-24 years) completed baseline and ecological momentary assessments. Cue exposure and participants' average stress predicted higher craving. Youth with weaker WM experienced stronger craving at higher-stress moments but not when faced with cues. Interactions were present for both previous-moment and same-moment stress. Craving among adolescents with stronger WM was not swayed by momentary stress. Findings suggest stronger WM protects against craving at more stressful moments.

Galantamine and Computerized Cognitive Behavioral Therapy for Cocaine Dependence: A Randomized Clinical Trial

OBJECTIVE

To examine whether galantamine, a cognitive-enhancing medication that is both acetylcholinesterase inhibitor and agonist at nicotinic acetylcholine receptors, is effective at improving cocaine use outcomes and cognitive functioning, alone and in combination with computerized cognitive behavioral therapy (CBT).

METHOD

A 12-week, randomized 2 × 2, factorial trial was conducted to evaluate galantamine versus placebo (double-blind) and computerized CBT plus standard methadone treatment versus standard methadone treatment alone in a community-based methadone maintenance program (September 2009-April 2015). One hundred twenty individuals diagnosed with DSM-IV cocaine use disorder were randomly assigned to the following conditions: (1) galantamine (8 mg/d) plus standard methadone maintenance treatment (treatment as usual [TAU]), (2) placebo plus TAU, (3) galantamine plus computerized CBT plus TAU, or (4) placebo plus computerized CBT plus TAU; medication administration was supervised at the time of daily methadone dosing. The primary cocaine use outcome was change in percent days of abstinence over time. Number of cocaine-negative urine toxicology screens submitted and cognitive function were secondary outcomes.

RESULTS

Random effect regression analysis indicated significant reductions in frequency of cocaine use over time, with significant treatment-by-time effects for both galantamine over placebo (F = 5.3, P = .02, d = 0.34) and computerized CBT over standard methadone treatment (F = 4.2, P = .04, d = 0.30) but no evidence of significant benefit of the combination over either treatment alone. Pretreatment to posttreatment comparisons of multiple indices of cognitive functioning, including sustained attention, indicated no benefit of galantamine over placebo.

CONCLUSIONS

Findings suggest benefits of galantamine and computerized CBT for reducing cocaine use in this sample. Although galantamine did not improve measures of cognitive function in this sample, multiple measures of cognitive function were associated with cocaine use outcomes, underlining the significance of cognitive function in cocaine treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00809835.

A transdiagnostic dimensional approach towards a neuropsychological assessment for addiction: an international Delphi consensus study

BACKGROUND

The US National Institutes of Mental Health Research Domain Criteria (RDoC) seek to stimulate research into biologically validated neuropsychological dimensions across mental illness symptoms and diagnoses. The RDoC framework comprises 39 functional constructs designed to be revised and refined, with the overall goal of improving diagnostic validity and treatments. This study aimed to reach a consensus among experts in the addiction field on the 'primary' RDoC constructs most relevant to substance and behavioural addictions.

METHODS

Forty-four addiction experts were recruited from Australia, Asia, Europe and the Americas. The Delphi technique was used to determine a consensus as to the degree of importance of each construct in understanding the essential dimensions underpinning addictive behaviours. Expert opinions were canvassed online over three rounds (97% completion rate), with each consecutive round offering feedback for experts to review their opinions.

RESULTS

Seven constructs were endorsed by ≥ 80% of experts as 'primary' to the understanding of addictive behaviour: five from the Positive Valence System (reward valuation, expectancy, action selection, reward learning, habit); one from the Cognitive Control System (response selection/inhibition); and one expert-initiated construct (compulsivity). These constructs were rated to be related differentially to stages of the addiction cycle, with some linked more closely to addiction onset and others more to chronicity. Experts agreed that these neuropsychological dimensions apply across a range of addictions.

CONCLUSIONS

The study offers a novel and neuropsychologically informed theoretical framework, as well as a cogent step forward to test transdiagnostic concepts in addiction research, with direct implications for assessment, diagnosis, staging of disorder, and treatment.

Effect of transcranial direct current stimulation on decision making and cognitive flexibility in gambling disorder

Decision making and cognitive flexibility are two components of cognitive control that play a critical role in the emergence, persistence, and relapse of gambling disorder. Transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex (DLPFC) has been reported to enhance decision making and cognitive flexibility in healthy volunteers and individuals with addictive disorders. In this triple-blind randomized sham-controlled parallel study, we aimed to determine whether tDCS over DLPFC would modulate decision making and cognitive flexibility in individuals with gambling disorder. Twenty participants with gambling disorder were administered Iowa Gambling Task (IGT) and Wisconsin Card Sorting Test (WCST). Subsequently, participants were administered three every other day sessions of active right anodal /left cathodal tDCS (20 min, 2 mA) or sham stimulation over bilateral DLPFC. WCST and IGT were readministered following the last session. Baseline clinical severity, depression, impulsivity levels, and cognitive performance were similar between groups. TDCS over the DLPFC resulted in more advantageous decision making (F_1,16 = 8.128, p = 0.01, ɳp² =0.33) and better cognitive flexibility (F_1,16 =8.782, p = 0.009, ɳp² = 0.35), representing large effect sizes. The results suggest for the first time that tDCS enhanced decision making and cognitive flexibility in gambling disorder. Therefore, tDCS may be a promising neuromodulation-based therapeutic approach in gambling disorder.Trial registration: Clinicaltrials.gov NCT03477799.

The Impact of Facebook Use and Facebook Intrusion on Cognitive Control: Effect in Proactive and Reactive Control

More and more people are using social networking sites, with Facebook being one of the most popular. So far, most of the research on using Facebook has focused on emotional, social, and personality-related factors and few studies have investigated the phenomenon from a cognitive perspective. The aim of our study was, therefore, to identify relationships between cognitive control and Facebook intrusion, with regard to proactive and reactive modes of cognitive control. The study was also designed to investigate the effects of neutral and Facebook-related context. The subjects (N = 80 young adults, M_age = 21.13 years; SD = 1.60) were divided into two groups based on their level of Facebook intrusion. The Facebook Intrusion Scale was used for selection. Using the AX-continuous performance task, we found that subjects with high Facebook intrusion showed more reactive control than their low Facebook intrusion peers. We also demonstrated that all subjects showed less proactive control in a Facebook-related context than in a neutral context. The results were interpreted in the light of the dual mechanism of cognitive control model.

Feasibility, Acceptability, and Initial Efficacy of Delivering Alcohol Use Cognitive Interventions via Crowdsourcing

BACKGROUND

Inhibitory control training and working memory training are 2 cognitive interventions that have been considered for alcohol use disorder (AUD). Existing studies have typically relied on small samples that preclude the evaluation of small effects. Crowdsourcing is a sampling method that can address these limitations by effectively and efficiently recruiting large samples with varying health histories. This study tested the feasibility and acceptability of delivering cognitive training interventions via crowdsourcing.

METHODS

Participants with AUD were recruited from the crowdsourcing website Amazon Mechanical Turk (mTurk) (ClinicalTrials.gov; NCT03438539). Following completion of a baseline survey, participants were randomized to an inhibitory control, working memory, or control training condition. Participants were asked to complete training tasks daily over a 2-week period. Follow-up assessments evaluating acceptability measures and alcohol and soda consumption were completed immediately following and 2 weeks after training.

RESULTS

Response rates were satisfactory over the 2-week intervention period (65% of training tasks completed), and performance on training tasks was consistent with expected effects. A majority of participants indicated that they were satisfied with the study procedures (94.6%), would participate again (97.4%), and would consider incorporating the training task in their daily life (81.1%). Modest reductions in alcohol consumption were observed (e.g., 0.5 drinking day/wk), primarily in the inhibitory control group, and these effects were selective to alcohol use and did not extend to soda consumption.

CONCLUSIONS

These findings demonstrate the feasibility and acceptability of utilizing crowdsourcing methods for interventions development. Such a demonstration helps establish the crowdsourcing setting for future large sample studies testing novel interventions for AUD and other substance use disorders.

A stepped wedge cluster randomised trial of a cognitive remediation intervention in alcohol and other drug (AOD) residential treatment services

BACKGROUND

Executive functioning impairment is common in substance use disorder and is a major risk factor for poor treatment outcomes, including treatment drop-out and relapse. Cognitive remediation interventions seek to improve executive functioning and offer a promising approach to increase the efficacy of alcohol and other drug (AOD) treatments and improve long-term therapeutic outcomes. This protocol describes a study funded by the NSW Agency for Clinical Innovation that assesses the effectiveness of delivering a six-week group-based intervention of cognitive remediation in an ecologically valid sample of people attending residential AOD treatment services. We primarily aim to investigate whether cognitive remediation will be effective in improving executive functioning and treatment retention rates. We will also evaluate if cognitive remediation may reduce long-term AOD use and rates of health service utilisation, as well as improve personal goal attainment, quality of life, and client satisfaction with treatment. In addition, the study will involve an economic analysis of the cost of delivering cognitive remediation.

METHODS/DESIGN

The study uses a stepped wedge cluster randomised design, where randomisation will occur at the cluster level. Participants will be recruited from ten residential AOD treatment services provided by the non-government sector. The intervention will be delivered in 12 one-hour group-based sessions over a period of six weeks. All participants who are expected to receive treatment for the duration of the six-week intervention will be asked to participate in the study. The clusters of participants who are randomly assigned to the treatment condition will complete cognitive remediation in addition to treatment as usual (TAU). Primary and secondary outcome assessments will be conducted at pre-cognitive remediation/TAU phase, post-cognitive remediation/TAU phase, two-month follow-up, four-month follow-up, six-month follow-up, and eight-month follow-up intervals.

DISCUSSION

This study will provide comprehensive data on the effect of delivering a cognitive remediation intervention within residential AOD treatment services. If shown to be effective, cognitive remediation may be incorporated as an adjunctive intervention in current treatment programs.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12618001190291 . Prospectively registered 17th July 2018.

Alcohol-Specific Computerized Interventions to Alter Cognitive Biases: A Systematic Review of Effects on Experimental Tasks, Drinking Behavior, and Neuronal Activation

Background: In patients with alcohol use disorder, novel interventions to increase abstinence have attracted growing attention. Interventions aimed at modifying cognitive biases linked to alcohol use [i.e. cognitive bias modification (CBM)] may serve as an add-on to standard therapy. This systematic review thoroughly aggregates existing data on the effects of three alcohol-specific computerized interventions, namely attentional bias modification (AtBM), approach bias modification (ApBM), and inhibition training (IT). In doing so, each CBM's effects on experimental tasks assessing the relevant biases, drinking behavior, and neurophysiology are summarized. Also, the influence of drinking behavior severity and motivation to change drinking behavior are discussed. Methods: A literature search was conducted in four databases for original research articles published between 2000 and May 2019. Studies were eligible if investigating the effects of alcohol-specific computerized interventions (AtBM, ApBM, IT) on drinking behavior, bias change, and/or neurophysiology. Forty eligible articles were classified as being either a non-clinical experimental lab study (ELS) or clinical randomized-controlled trial (RCT) and summarized. Results: While AtBM seems to influence attentional bias, its effects on drinking behavior are inconsistent. As for ApBM, the best effects on drinking behavior are obtained in clinical samples. Effects of ApBM on approach bias are mixed. Interestingly, those clinical RCTs which investigated ApBM effects on bias change as well as on drinking outcome, reported consistent effects in both measures (i.e. either effects on bias and drinking or no effects). Studies on IT are limited to non-clinical samples and show inconsistent effects on drinking behavior. Considering ITs effects on implicit semantic associations, most studies do not support the conceptualization of IT as a form of memory bias modification, while reports on IT's effects on inhibitory control are still incomplete. Conclusions about the overall influence of drinking behavior severity are hampered by the non-uniform use of sample descriptions. Conclusions: In clinical samples, ApBM has shown more consistent beneficial effects, while evidence on AtBM is more inconsistent, and data on IT still lacks important information. Conclusions about the influence of drinking behavior severity would be facilitated by a uniform use of clearly defined sample descriptions.

A Roadmap for Integrating Neuroscience Into Addiction Treatment: A Consensus of the Neuroscience Interest Group of the International Society of Addiction Medicine

Although there is general consensus that altered brain structure and function underpins addictive disorders, clinicians working in addiction treatment rarely incorporate neuroscience-informed approaches into their practice. We recently launched the Neuroscience Interest Group within the International Society of Addiction Medicine (ISAM-NIG) to promote initiatives to bridge this gap. This article summarizes the ISAM-NIG key priorities and strategies to achieve implementation of addiction neuroscience knowledge and tools for the assessment and treatment of substance use disorders. We cover two assessment areas: cognitive assessment and neuroimaging, and two interventional areas: cognitive training/remediation and neuromodulation, where we identify key challenges and proposed solutions. We reason that incorporating cognitive assessment into clinical settings requires the identification of constructs that predict meaningful clinical outcomes. Other requirements are the development of measures that are easily-administered, reliable, and ecologically-valid. Translation of neuroimaging techniques requires the development of diagnostic and prognostic biomarkers and testing the cost-effectiveness of these biomarkers in individualized prediction algorithms for relapse prevention and treatment selection. Integration of cognitive assessments with neuroimaging can provide multilevel targets including neural, cognitive, and behavioral outcomes for neuroscience-informed interventions. Application of neuroscience-informed interventions including cognitive training/remediation and neuromodulation requires clear pathways to design treatments based on multilevel targets, additional evidence from randomized trials and subsequent clinical implementation, including evaluation of cost-effectiveness. We propose to address these challenges by promoting international collaboration between researchers and clinicians, developing harmonized protocols and data management systems, and prioritizing multi-site research that focuses on improving clinical outcomes.